Palliative medicine

Palliative patient care depends on our understanding of the human being: Does it simply aim for sufficient symptom control in patients with terminal illness until what we consider to be the end of their life, or does it develop future-oriented perspectives in therapy, mental and emotional support and spiritual accompaniment? The therapeutic needs of palliative patients are threefold: They need not only symptom-oriented treatment, but also a salutogenetic approach in palliative care. They need mental and emotional support in times of doubt, denial and existential fear of the illness that often underlie their depressive, hopelessness-tempered experience. And finally, every human being – and especially a terminally ill patient – needs perspective and hope to survive – needs the human ability to look toward the future. We can see parallels to pregnancy, labour and the moment of birth: When speaking of death, we also speak of varying durations of the death process, and of the moment of death, and see important inner developments, self-actualization, and with it autogenesis in these condensed phases of treatment, that point to a kind of spiritual birth.

Conversely, the most significant reasons for the wish for actively assisted suicide lie in these three areas. The wish seldom results from no-longer-controllable somatic symptoms in the palliative phase of illness. More often, it is depression, mental and/or emotional desperation and the feeling of being a burden to others. But the main cause is the loss of a sense of meaning: What is the point of this suffering, if death can just come and “take care of it all”? In such cases, meaningful patient accompaniment is crucial. Naturally, this depends on the attending physician’s views on death and dying, on her ethical capacity in making decisions, and therefore on her inner development. It is not only the patient who develops as a person through the illness – the attending physician must also actively develop professionally and ethically. The foundations of a patient-physician relationship in palliative care consist not only of professional competence and empathic relating, but also of therapeutic engagement. As soon as the patient experiences this will to heal, he feels supported on his own path of treatment. Considerations of actively assisted suicide often then disappear: it is perceived as an ineffectual solution and insufficient response to the loss of a sense of meaning and perspective. Assisted suicide is then seen as “deadly compassion” as defined by Klaus Dörner. In contemporary palliative care, most symptoms can be controlled with medication. Anthroposophical remedies give us a further, essential tool for treatment in palliative care. Anthroposophical nursing and physiotherapy are extremely significant external applications. Art therapies open the mental and emotional experience of the patient, and awaken inner activity. In talking therapy, questions of individual values, biographical context and goals are taken up, and tools developed for handling changeable mental and emotional states. This includes the spiritual and religious convictions of the patient, touches on questions of destiny, life after death, and reincarnation.

The collaboration of the different therapists creates a therapeutic community that can be astonishingly helpful even in situations of extreme suffering. With its help, patients who actively wish to die can often develop new perspectives and actively use this special time with its condensed capacity for development. The essential characteristic of anthroposophical palliative medicine is its orientation toward the developmental and future-bearing capacity of human beings, whose soul and spiritual being is not bound by the physical limitations of birth and death.

The principles of ethical decision-making in regard to actively assisted suicide follow from these three dimensions of the human being. On the level of somatic observation, it appears as if a phase of illness filled with pain and suffering “finally” ends; patient and attending physician assume that this is a “release”. However, if we include the soul and spiritual levels, completely different perspectives unfold. Now it has not only to do with autonomy of decision-making, but with a thorough scrutiny of the capacity for autonomy in both the patient and the attending physician: Are we able and capable to make this judgement, not only on a somatic level, but also on a spiritual scientific level? Is the attending physician’s ethical professionalism as developed as her medical professionalism? If we see the human being as gifted with spirit, predisposed to development toward the future even in the face of the mortal body, then in actively assisting a death we are taking from the patient the most essential thing that can arise through illness – are potentially creating, through the seeming ending of pain and suffering, a new pain – a feeling of loss, privation and suffering. In this sense, we are not assisting a “release” from pain, only a relocation – possibly even simply a dislocation into a realm not intended for such. Observation of the often deep development in the palliative phase of illness brings a certainty regarding self-actualization in the process of dying and evokes the image of death as a moment of birth: “When a spirit dies, it becomes a human being. When a human being dies, he becomes a spirit”, writes Novalis. In three decades working as a physician, one meets innumerable patients who wish to die. Almost without exception, however, patients are able to find new meaning through therapy – through soul and spiritual support – and to develop both the strength to bear their situation and a new autonomy. Then, a patient is not “ill”. Instead, she “has” an illness – she experiences herself as autonomous, even in the palliative phase of the illness. In no way is her dignity taken from her, in the sense that she must spend her time in “undignified suffering”; on the contrary, she gains dignity in a special way in this phase of illness. Medically assisted suicide sees a lack of dignity in suffering. It does not recognize that every human being in every situation has his human dignity and that terminally ill patients can also experience it (this continues to prove true) with the support of good palliative and hospice care. Palliative medicine that orients itself toward human beings and their development, including in their later years, cannot orient itself against the individual through actively assisted suicide in the sense of “humanitarian killing”. Of course, there are some rare cases of uncontrollable symptoms where palliative sedation may be necessary; but even in such cases, actively assisted suicide is not a necessary tool.